Assessment of hearing and vision impairment in cohort studies collecting cognitive data in older adults.

INTRODUCTION: There are no standard practices for considering sensory impairment in studies measuring cognitive function among older adults. Exclusion of participants with impairments may inaccurately estimate the prevalence of cognitive impairment and dementia. METHODS: We surveyed prospective cohort studies measuring cognitive function in older adults, determined the proportion that excluded participants based on sensory impairment and the proportion that assessed each type of sensory impairment, and described the methods of sensory assessment. RESULTS: Investigators/staff from 85 (of 192 cohorts) responded; 6 (7%) excluded participants with severe impairment; 80 (94%) measured hearing and/or vision impairment, while 5 (6%) measured neither. Thirty-two (38%) cohorts assessed hearing objectively and 45 (53%) assessed vision objectively. DISCUSSION: Findings indicate variation in methods used to assess sensory impairment, with potential implications for resource allocation. To ensure equitable inclusion of study participants, consensus is needed on best practices standardized protocols for assessment and accommodations of sensory impairment.

Barriers to medication adherence in a rural-urban dual economy: a multi-stakeholder qualitative study.

BACKGROUND: One of the most cost-effective treatments for secondary prevention of stroke and other non-communicable diseases is a long-term medication regimen. However, the complexities of medication adherence extend far beyond individual behavior change, particularly in low- and middle-income countries. The purpose of this study was to examine stakeholder perspectives on barriers to medication adherence for stroke patients in Beijing, China, identifying opportunities to improve care and policy in resource-constrained settings. METHODS: We conducted a qualitative, phenomenological analysis of data obtained from 36 individuals. Participants were patients; caregivers; healthcare providers; and representatives from industry and government, purposively selected to synthesize multiple perspectives on medication management and adherence for stroke secondary prevention in Beijing, China. Data was analyzed by thematic analysis across iterative coding cycles. RESULTS: Four major themes characterized barriers on medication adherence, across stakeholders and geographies: limitations driven by individual patient knowledge / attitudes; lack of patient-provider interaction time; lack of coordination across the stratified health system; and lack of affordability driven by high overall costs and limited insurance policies. CONCLUSIONS: These barriers to medication management and adherence suggest opportunities for policy reform and local practice changes, particularly for multi-tiered health systems. Findings from this study in Beijing, China could be explored for applicability in other low- and middle-income countries with urban centers serving large geographic regions.

Assessment of Trends in Guideline-Based Oral Anticoagulant Prescription for Patients With Ischemic Stroke and Atrial Fibrillation in China.

Importance: Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. Objective: To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. Design, Setting, and Participants: This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. Exposure: Calendar year. Main Outcomes and Measures: Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescribing of OACs (warfarin and non-vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. Results: Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (P < .001 for trend). Of 49 531 eligible patients (26 028 men [52.5%]; mean [SD] age, 73.4 [10.4] years), 20 390 (41.2%) had an OAC prescription at discharge, an increase from 23.2% (36 of 155) in the third quarter of 2015 to 47.1% (403 of 856) in the third quarter of 2019 (P < .001 for trend). Warfarin was the most commonly prescribed OAC (11 956 [24.2%]) and had the largest temporal increase (from 5.8% [9 of 155] to 20.7% [177 of 856]). Older age (adjusted odds ratio [aOR] per 5 year increase, 0.89;95% CI, 0.89-0.90), lower levels of education (aOR for below elementary school, 0.84; 95% CI, 0.74-0.95 ), lower income (aOR for ≤¥1000 [$154], 0.66; 95% CI, 0.59-0.73), having new rural cooperative medical scheme insurance (aOR, 0.92; 95% CI, 0.87-0.96), prior antiplatelet use (aOR, 0.70; 95% CI, 0.66-0.74), having several cardiovascular comorbid conditions (including stroke or transient ischemic attack [aOR, 0.78; 95% CI, 0.75-0.82], hypertension [aOR, 0.84; 95% CI, 0.80-0.89], diabetes [aOR, 0.91; 95% CI, 0.83-0.99], dyslipidemia [aOR, 0.87; 95% CI, 0.80-0.94], carotid stenosis [aOR, 0.83; 95% CI, 0.69-0.98], and peripheral vascular disease [aOR, 0.80; 95% CI, 0.71-0.90]), and admission to secondary hospitals (aOR, 0.71; 95% CI, 0.68-0.74) or hospitals located in the central region of China (aOR, 0.80; 95% CI, 0.75-0.84) were associated with not being prescribed an OAC at discharge. Conclusions and Relevance: This quality improvement study suggests that, despite significant improvement over time, OAC prescriptions remained low. Efforts to increase OAC prescriptions, especially non-vitamin K OACs, are needed for vulnerable subgroups by age, socioeconomic status, and presence of comorbid conditions.

Association of formal and informal care with health-related quality of life and depressive symptoms: findings from the Caring for Adults Recovering from the Effects of Stroke study.

AIM: To investigate the association between informal and formal care and stroke participants' self-reported health-related quality of life and depressive symptoms one year after the stroke event. METHODS: We examined a national population-based sample of 123 stroke participants. Care received was defined as formal (outpatient therapy, care from home health aides, nurses, or therapists), informal (family caregiver), or shared (formal and informal). Hours of care were extracted from Medicare claims and caregiver self-report. A general linear model was used to compare health-related quality of life and depressive symptoms one year after the stroke for those who received shared care, only informal care or only formal care to those with no post-stroke care. RESULTS: Among stroke participants, 12.2% received only formal care, 35.0% only informal care, 38.2% shared care, and 14.6% no care. Those with only informal care had greater self-reported depressive symptoms than those who received no care at all. CONCLUSIONS: Shared care was the most common care configuration for stroke participants, but no significant associations were found between shared care and self-reported outcomes after adjusting for stroke participant characteristics. Further research is needed on the dose of informal and formal care and their coordination to better understand relationships with recovery.IMPLICATIONS FOR REHABILITATIONStroke is one of the leading causes of disability for adults in the USA and ongoing care is needed for survivors.Informal caregivers such as family members play an important role in recovery in addition to formal care provided by home health aides, nurses and therapists.This study showed that survivors with informal care had more severe depressive symptoms, while shared care provided by formal and informal caregivers may prevent further decline in patients with worse baseline health.

Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study.

BACKGROUND: Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women. METHODS: Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability. RESULTS: A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately]. CONCLUSIONS: AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.